Six months back Mr. M., aged 58 years, working as news editor in a Malayalam news channel, came to me for consultation. He admitted that he was taking daily 5 or 6 tablets of alprazolam, an anti-anxiety drug, for the last 12 years! He narrated the story how he became dependent on or rather addicted to the sedative drug. Twelve years ago he approached a physician to get a prescription for the relief of his mental tension and sleeplessness which he experienced frequently for some time. The physician prescribed alprazolam 0.25 mg to be taken at bed time. After using it for about 6 months he couldn’t get sufficient sleep with just one tablet. Therefore he increased the dose to two tablets. A few months after increasing the dose to two tablets Mr. M. started taking three and then four. When he came for consultation he was taking 6 tablets daily at bed time to get sufficient sleep and one or two in day time to avoid tension and to get “some satisfaction”. If he didn’t take 5 or 6 tablets daily he became jittery and sleepless. Now he is very much worried about his drug addiction and wanted to get rid of the drug and overpower his mental tension.
He described his psychological problem. He experiences mental tension on silly matters. For example when he is entrusted with covering a program by the news channel he gets tensed. Sometimes all of a sudden he becomes jittery and feels hot flush on face and chest and butterflies in the stomach. He wanted to get rid of this psychological disorder without taking any medicine.
In fact he was suffering from two problems, viz. General Anxiety Disorder [GAD] and drug addiction or Substance Use Disorder [SUD]. So he should get rid of GAD and SUD simultaneously. The first step in overpowering anxiety without medicine is to understand what anxiety is. So I started a psycho-education process.
The anxiety response
The anxiety response is a normal, vital reaction to threat. When we perceive danger our bodies rapidly produce adrenaline that pimes us to respond to dangerous situations. The classic responses are ‘fight’ which means challenging the threat directly or flight, that is, escaping from or avoiding the threat. When faced with perceived threat, we feel fear and the mind and the body get ready to deal with it. The mind considers the worst-case-scenario, and the body prepares to tackle it. The responses reflect on all the four systems: emotional, cognitive, physiological and behavioural. Consider the following responses:
A mother is standing at the side of the road close to her son. A bus is heading towards them. The mother has a fleeting image of her son stepping into the road in front of the bus. She feels fear. Her adrenaline rises, she becomes tense, focused and primed for action. Swiftly, she takes son’s arm, despite his protestations, and hold him close to her as the bus passes them safely.
Thus, the anxiety response is normal and largely unconscious process that regularly occurs in each of us. Anxiety only becomes a problem when the normal response is exaggerated or occurs in the absence of real threat. Mr. M. frequently thought his work as a journalist is not satisfactory and the news channel may fire him. Occasionally when these thoughts came to his mind he had panic attacks.
Every journalist may doubt whether his performance is satisfactory or not. In this case fear is exaggerated and Mr. M. developed an anxiety disorder. Two individuals can be in precisely the same situation but anticipate different consequences and, therefore, react in different ways.
Characteristics of anxiety and anxiety disorders
In normal individuals the psychological process dealing with anxiety is linear as shown below:
Trigger à perceived threat à anxiety response à successful coping reaction à resolution of anxiety.
A driver sees a child run out in front of a car à production of adrenaline à this promotes quick and focused thinking which enables the driver to brake and swerve in time à resolution of anxiety.
In persons with anxiety disorder the psychological process is circular as shown below:
Trigger à perceived threat à Exaggerated anxiety response à unhelpful coping reaction àunresolved problem à perceived threat (the cycle goes on) (See the figure)
|The Cycle of Anxiety in GAD|
Example: An anxious student learns of an impending oral assessment à he finds this threatening and experiences high levels of anxiety à his thinking becomes overly focused on the exam and he becomes tense that she cannot study effectively à he does not perform well in the assessment; this promotes his belief that he is incapable, and he remains a highly anxious student.
The ultimate fear cycle is ‘fear of fear’ where the experience of anxiety itself becomes aversive and is therefore avoided long after the original trigger for the anxiety has receded. Once Mr. M. thought he had heart attack. He was taken to the hospital. At the hospital he was assured that he had experienced a panic attack. Mr. M. was not totally relieved by this, as he had found the panic attack so unpleasant that he now lives in dread of it happening again.
Anxiety disorders are characterized by distorted beliefs about the dangerousness of certain experiences. Essentially, anxiety disorders are perpetuated by how we feel, what we think and what we do.
Changes in behaviour needed to overpower anxiety disorder
Mr. M. was not in the habit of doing any physical exercise. I advised him to do brisk walking for 45 – 50 minutes daily. He was advised to do the progressive muscular reaxation daily.
In order to get rid of the drug addiction I advised him to reduce the dose of alprazolam at the rate of one tablet per month.
With these cognitive and behavioural efforts for 6 months Mr. M. got rid of both anxiety disorder and drug addiction.